Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, January 7, 2008

Learning for next time

I didn't want to operate on this guy. He's 86 and suffers from emphysema and CHF. In the past year I've operated on him three times. The first time I was covering for my partner who had removed a large basal cell carcinoma from his back earlier that day. He came back later in the middle of the night with a giant hematoma and I drained it, placed a JP in the OR. Two months later he came into the ER with an incarcerated right inguinal hernia. I took him emergently to the OR and fixed it, resecting about 8 cm of small bowel that had become ischemic. He recovered nicely and by this time we had become buddies. He had a left inguinal hernia as well, and I told him he needed to have that one fixed too, as soon as he recovered completely. So, we set a date for elective repair, but he shows up in the pre-op area tachycardic and basically looking like hell. The hernia looked to be incarcerated and the overlying erythematous skin, leukocytosis, and acidosis was suggestive of advanced bowel ischemia. How long has it been like this, I increduously asked his wife? All weekend, she said. He didn't want to come in though. I found incarcerated, gangrenous sigmoid colon in the hernia and performed a sigmoid resection with end colostomy, in addition to fixing the hernia. This time he was sick as all hell. Respiratory and renal failure. Prolonged ICU stay. Pneumonia. But eventually he recovered. He went to a rehab facility. Ultimately, he went home. He gained weight. His cantankerous humor returned. He came to see me in the office every few weeks or so, not because he needed to, he just liked coming in to see me. You're like a son to me, he said one time, breaking down and crying right there in the little exam room in front of his wife. I liked him. He was more than just a patient. He was my buddy. We'd been through a lot together. But he wasn;t happy. The colostomy was "killing" him. He hated it. He told me he'd rather die than live the rest of his life with it. I went through the risks. I told him that another operation might very well be the end of him. He'd been through too much at 86 years old. But he was relentless. I half-heartedly referred him to a cardiologist and pulmonologist for preoperative clearance, fully expecting them to put the kibosh on any further surgical intervention. To my surprise I got letters from both saying, as long as he understood the high risk nature, he would be cleared for surgery without need for further testing. So there he was, about 8 weeks ago, sitting in my office, eyes beaming, adamant, asking when his surgery could be arranged. You really want to do this, I asked him? At the risk of death? At the risk of maybe never seeing your wife again? Yes, he said. Please get rid of this colostomy. So I scheduled him. The surgery went beautifully. Post op day #1, however, his lungs sounded like an evening tide had rolled into his alveoli. He was intubated within hours. He'd gone into heart failure and developed pneumonia shortly after being mechanically ventilated. He went into ARDS. I watched his eyes go blank, the muscle mass he'd rebuilt slowly waste away. Every day for a month it was the same. I studied his anastomosis and it was intact; his bowels started to function normally after five or six days. Eventually, his lungs started to bounce back but not before I had to place a tracheostomy and a feeding gastrostomy tube. He's almost ready for transfer out of the hospital to a long term care facility, which is a minor triumph. But every time I go into his room, I say good morning Bill and he turns his head and looks away. He looks out the window with his glassy, sunken eyes. I shouldn't have done this to you Bill, I think. I should have been stronger in saying no.....There are different degrees of failure in surgery; technical errors, laziness, lack of foresight. Judgment failures are the ones you can't prepare for in textbooks. You have to learn them on your own.

11 comments:

Anonymous
said...

How do you say no to a patient when they are as adamant as this one was?

I find your telling of this very thoughtful and mindful of this man's quality of life. I've seen a lot of post-op patients who were bewildered and/or angry with their ostomies/tubes, etc., and it always made me wonder: were you listening? was the doctor? what happened here?

Thank you for sharing your experiences! So many times, my internal medicine colleagues try to push me into doing a surgical case against my better judgement. I had a wise old attending telling me many years ago, "A good surgeon is one who operates well, a better surgeon is one who knows when not to operate."

I have gotten the impression from one of our surg onc guys that he has expected cardiology to say that pt's shouldn't have surgery. However, we generally don't make those types of recommendations. It is more an assessment of risk and interventions to try to mitigate cardiac risk. I have been quite surprised that some of the patients that we see are even being considered for surgery.As a surgeon are you expecting a consult to say that surgery is not advised?

Recently had to hammer home to a vascular surgeon that his pt was extremely high risk for 7 cm AAA repair and there was nothing to be done to improve the risks. The pt apparently was insisting on surgery as his father died of a ruptured AAA and he did not want a similar death. After consultation with 2 cardiologists and the surgeon it was decided not to pursue AAA repair.

I certainly don't see your decision as a poor judgement call. He was adamant and made his choice very clear. You carefully explained all of the risks and tried to discourage him, all to no avail. He may have many reasons for looking away when you enter the room, and none of them may have anything to do with resentment towards you.He is obviously a fighter, I hope he pulls through.

For what it's worth, I would probably have offered to reverse his stoma, too. "I'd rather die than live with a colostomy" are powerful words. And since he knew he could die or have a really rocky road, then it's his decision. I hope he does well in rehab.

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